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Sunday, April 28, 2013

More on cancer screening futility

For every complex problem there is a simple solution... and it is wrong. - H. L. Mencken

Dr. Bloodgood had a simple idea. Identify cancer in its early stage and cut it out. As it turns out, this appears to work well for certain cancers such as cervical cancer. However, this observation does not appear to be particularly generalizable. It has taken almost a century and many attempts before the reality of the futility has begun to sink in.  In today's New York Times Magazine there is an article published by Peggy Orenstein, a breast cancer survivor who writes of her medical and intellectual journey "Our feel good war on breast cancer".  It is a well written and reasoned article, written by a sophisticated patient from a patient perspective. That journey has led her to the following conclusions:
"It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk."
I am not sure that it will have any immediate impact. These concepts have been around for more than a decade and have failed to gain traction. I am biased in that I think they are correct but perhaps I am wrong. I doubt it. Dr. Bert Kramer wrote in his article in the Annual Review of Medicine entitled: Cancer Screening: The Clash of Science and Intuition* (Annual Review of Medicine - Vol. 60: 125-137 (Volume publication date February 2009) 
As Roman playwright Terence noted, “One easily believes what one earnestly hopes for.” 
Science, medicine, politics, and belief all converge. The screening industry is embedded into the business model for medicine and has strong allies among non-profits. It is not limited to breast cancer and it is a powerful model for public involvement. Our intuition creates the state where the default is to believe that screening should and does work and there a huge financial incentives to keep this model in place. 

Attempts to disseminate information which is contrary to our intuition will be pounced upon by believers as to be motivated by less than virtuous motives, particularly at a time where health care becomes more and more resource constrained.  However, it is even more important that this be sorted out in a time of increasing scarcity. If this a waste of time and resources can be devoted with better return elsewhere, it is stupid to continue to throw good time and money toward activities that provide no real value. I have few doubts that we will continue to throw "public" resources in the form of insurance dollars at this but I can't help but wonder if individuals would spend their own precious personal resources if they were aware of the likely return (or lack thereof) on their investment. 


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